Acute Anemia in a Patient With Hepatocellular Carcinoma

Abstract

Question: A 64-year-old man presented with syncope. He had been diagnosed with a multifocal hepatocellular carcinoma (HCC) Barcelona Clinic Liver Cancer stage D 2 months before admission. He denied prodromes, hematemesis, melena, or abdominal pain, and there was no recent history of abdominal trauma. At admission, he was pale and tachycardic, presented with grade 3 ascites (International Ascites Club Classification) and the neurologic examination was unremarkable. Laboratory data revealed de novo normocytic and normochromic anemia (hemoglobin, 4.3 g/dL; normal range, 11.5–18.0) and prothrombin time of 60% (normal, 70%–100%). Upper gastrointestinal endoscopy revealed only small esophageal varices with no stigmata of recent hemorrhage. Paracentesis revealed a bloody fluid with serum–ascites albumin gradient of 1.4 consistent with portal hypertension, 2.4 g/dL of proteins, and 500 cells/mL with predominance of lymphocytes and mesothelial cells, erythrocyte count was not available. Cytology was negative for malignant cells. CT angiography (Figure A) was performed. What is the likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.